Grant: Operating Grant

Thousands of patients suffer severe brain injuries every year, from causes such as trauma, stroke, and infection. Many of them will have impaired consciousness and therefore be unable to keep food or mouth secretions from entering their lungs (called aspiration). To protect against aspiration, these patients require artificial respiration and intubation with a temporary breathing tube inserted through the mouth into the lungs. After the early phases of illness, doctors can use a test called a spontaneous breathing trial to assess when artificial respiration can be discontinued. Many patients with severe brain injury, however, pass this test yet still have impaired consciousness and an ongoing risk for aspiration. Unfortunately, little evidence exists to guide decisions about when to remove the breathing tube in these patients. There are different approaches that are commonly used in this situation. One approach involves simply discontinuing artificial respiration and removing the breathing tube, accepting that aspiration may still occur but reducing the potential for harm associated with prolonged artificial respiration. The other treatment is to perform a tracheostomy. A tracheostomy involves neck surgery to insert a new tube directly into the trachea, replacing the temporary breathing tube. The usual clinical practice is often just to keep the patient on artificial respiration for longer in the hope that the patient will wake up before removing the tube, or performing a tracheostomy if they don't wake up. Each strategy has risks and benefits, and uncertainty about the best approach often leads to prolonged use of the temporary breathing tube. This randomized controlled trial will test whether removing the temporary breathing tube as soon as possible after the patient passes a spontaneous breathing trial leads to better patient outcomes compared to performing a tracheostomy, or to the usual approach of waiting longer.